On cardiology training

I recently received a letter from a former fellow who completed his training almost 25 years ago, thanking me for guiding him through his education and to his successful medical career. It’s one of those letters that we all have received and that makes us feel that it is all worth it. When he went through his requisite 2 years of training, it seemed to me that my responsibility was to provide a model of how to provide excellent care at the bedside and clinic with expertise and compassion.

Dr. Sidney Goldstein

At that time, our tools were limited, and much of what we did was to provide what would be defined today as terminal care of the cardiac patient. Within a few years after this fellow finished training, there was an explosion of new technology and drugs that opened up the opportunity to treat the cardiac patients rather than just cataloging their demise. Just being a kind and informed doctor who listened to the patient was no longer enough.

Percutaneous coronary angiography, echocardiography, radioisotope imaging, and new dramatically effective lifesaving drugs such as beta-blockers, ACE inhibitors, and thrombolytic therapies were developed almost overnight. Their application to the patient became a challenge, and an exciting period of clinical research ensued. As a training director, it seemed that our responsibility was not only to continue to provide a model of competent care but also to create an environment in which our new tools of diagnosis and therapy could be applied at the bedside. At the time, it became apparent that there was a need for staff members to develop expertise in all of these areas in order to provide an adequate teaching environment. These new developments also provided a unique opportunity to conduct clinical research in order develop the full range of the new therapeutic and diagnostic potentials.

Within a few years, we changed from being the bedside cardiologists who could do everything in a very limited way, to a staff focused on special areas of expertise in order to provide an optimal teaching environment. This led to the development of subspecialty areas of cardiac care, which became the future framework of the contemporary cardiology unit. It resulted in a decreased time on bedside care and a greater emphasis on pursuing specialty care. Many of the aspects of interpersonal relationships at the bedside became less important in order to provide trainees with the sufficient experience in the newly developing subspecialty areas. The competence of a cardiology fellow was no longer judged by his commitment to patient care but rather, by the achievement of sufficient number of procedures to meet certification exams. Both students and teachers became focused on the numbers game.

It is clear that the body of cardiology knowledge has expanded to a point where most of us cannot handle it all, and we need to turn to our colleagues with special expertise for help. This transition, which is not unique to cardiology, removed the teacher-practitioners from their role as the model of ethical and compassionate caregiver to that of the provider of procedures. Now, more than ever, there is a need to return to the model of the compassionate and concerned doctor. The need for expertise is undeniable, but in the process of achieving that, we cannot forget that we are doctors to patients and not just procedure readers and number crunchers. There is still time in our day to do that. If there isn’t, we need to find it.

Dr. Goldstein, medical editor of Cardiology News, is professor of medicine at Wayne State University and division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit. He is on data safety monitoring committees for the National Institutes of Health and several pharmaceutical companies.